Biggest Patient Safety Concerns

April 25, 2014
Laura Joszt

Patient safety is a huge part of every healthcare organization and poor patient safety can severely affect the bottom line of any practice, hospital, or healthcare system.

Patient safety is a huge part of every healthcare organization and poor patient safety can severely affect the bottom line of any practice, hospital, or healthcare system.

ECRI has released the Top 10 Patient Safety Concerns for Healthcare Organizations, created from over 300,000 events collected since 2009, according to Karen P. Zimmer, MD, MPH, FAAP, medical director of ECRI Institute’s patient safety, risk, and quality group and of ECRI Institute Patient Safety Organization (PSO).

“In a time of competing priorities and limited resources in healthcare, we encourage facilities to use the list as a starting point for patient safety discussions and for setting their patient safety priorities,” Zimmer said in a statement. “ECRI Institute PSO has been collecting and analyzing events since 2009 and there are sufficient data to share recurring themes and associated prevention strategies.”

There is some overlap between this patient safety list and another of ECRI’s annual lists: the top health technology hazards. In particular 3 areas were similar to the technology hazards: data integrity failures in health information technology systems; retained devices and unretrieved fragments; and inadequate reprocessing of endoscopes and surgical instruments.

“While we see a lot of hazards with medical devices at ECRI Institute, we also see a large amount of errors in processes and systems,” says Barbara G. Rebold, RN, MS, CPHQ, ECRI Institute’s director, PSO operations, and director, Insight assessment services.

Here are the 10 biggest patient safety concerns and ways healthcare organizations can address the events and prevent them from occurring.

10. Inadequate reprocessing of endoscopes and surgical instruments

If a step in instrument reprocessing is missed, there could be a transmission or infectious agents and the spread of diseases such as hepatitis C and HIV.

“If there is pressure to meet procedure volume, we can see steps skipped to hasten the turnaround,” James P. Keller, M.S., vice president, technology evaluation and safety, ECRI Institute, said in the report.

Staff should be trained in protocols and sufficient time to perform the procedures correctly.

9. Inadequate monitoring for respiratory depression in patients taking opioids

Respiratory depression as an effect of opioids is often preceded by sedation. Unfortunately, sedation, the most important indicator of respiratory depression, is not adequately understood, according to the report. Signs of sedation include being frequently drowsy and drifting off to sleep during conversation.

Along with a pain scale to see if a patient’s pain is controlled, you also want to look at sedation,” Stephanie Uses, Pharm.D., M.J., J.D., patient safety analyst at ECRI Institute PSO, said in the report.

8. Patient falls while toileting

Patient falls are among the top safety events reported and represent roughly a quarter of all events. Unfortunately, preventing a fall while a patient uses the restroom is challenging as providers want to give the patient privacy and dignity.

Strategies to prevent patient falls while toileting include limiting attachments that can be tripping hazards to patients, and conducting falls risk assessments on all patients.

7. Retained devices and unretrieved fragments

Surgical items left in a patient after surgery, childbirth, or an interventional diagnostic procedure is an unfortunate issue that continues to occur, even though it is largely preventable. As a result of this issue, patients could suffer prolonged or additional surgery or future complications if the item leads to infection.

Preventing retained items can be done by adhering to accepted surgical count procedures, using X-ray imaging, and visually inspecting devices before and after use.

Image from Mashable

6. Mislabeled specimens

Nearly a third of all events reviewed were mislabeled specimen, making it the leading type of event in the laboratory testing process. Mislabeling may occur if the collector is distracted by a heavy workload which results in a forgotten label or an incorrect label.

Organizations can prevent labeling mistakes by adopting a practice of using 2 patient identifiers to identify the patient before the specimen is fathered and to label the specimen container immediately after collection.

5. Failure to adequately manage behavioral health patients in acute care settings

Staff in acute care settings has reported challenges in managing the behavioral health needs of patients exhibiting psychiatric illness or emotional agitation in addition to their clinical needs. According to ECRI, many reports describe patient violence incidents that harm the patient, staff or others.

“We need more attentiveness to behavioral health issues in healthcare overall,” Ruth Ison, M.Div, STM, patient safety analyst/consultant at ECRI Institute PSO, said in the report. “We have to bridge those knowledge gaps and really increase healthcare staff’s understanding of behavioral health symptoms that can appear anywhere throughout the care spectrum.”

Warning signs of potential patient violence include shouting, demanding behavior, excessive fear or paranoia, and possibly signs of substance intoxication.

4. Drug shortages

The best way to combat this issue is by developing a proactive plan to manage any future drug shortages, including assigning a task force to monitor impending shortages. The organization’s task force should keep an eye on the US Food and Drug Administration’s website on drug shortages and the American Society of Health-System Pharmacists drug shortage website.

Any action plan to address drug shortages should include documenting shortages and approving alternative to drugs that are unavailable or in short supply and providing an annual report on shortages and their effect on the organization to leaders.

3. Test results reporting errors

There are a variety of reasons why a breakdown in test result reporting could occur. Unfortunately, these breakdowns can contribute to bigger delays in patient care and diagnosis.

According to ECRI, test results reporting errors represent 10% of all events reviewed for this analysis. Organizations can reduce this issue with policies and procedures to guide reporting of results.

Included in the policies should be information on the process for reporting abnormal findings and what is the expected timeframe for providers to review the results.

2. Poor care coordination with patient’s next level of care

Despite the fact that best practice is for hospitals to send discharge information to all providers, the data show that there are gaps in communication about patient care between hospital and providers, among providers, and between long-term care settings and hospitals.

Patients can get moved around more frequently as a result of pressure to shorten hospital stays, which causes many patients to be discharged to post-acute care settings.

One way to improve care coordination is to have preadmission nurses from the post-acute setting to evaluate the patient before discharge and prepare the post-acute provider for the patient.

1. Data integrity failures with health information technology systems

Use of EHR systems tripled between 2009 and 2012. Incorrect data can lead to incorrect treatment and potentially lead to patient harm.

Data entry errors, missing data or delayed data delivery, inappropriate use of default values, copying and pasting older information into a new report, use of both paper and electronic systems for patient care, and patient/data association errors are all ways that data integrity can be compromised.

System testing is necessary to ensure that the system works as it should, and sufficient user training support and training is another important safeguard.